The Impact of a Daily Goals Tool in the ICU: More than a Checklist

Transcription

1 S Y S T E M The Impact of a Daily Goals Tool in the ICU: More than a Checklist May 24, 2016 Our Vision To be the Nation's leading public academic health care system. Leading. Teaching. Caring.

2 Acknowledgements NSICU Sharmila Soares, CN IV Christa Williams, Nurse Manager Megan Brissie, Nurse Practitioner Helen Nester, Nurse Practitioner Lissy Olivencia- Simmons, Nurse Practitioner Sarah Biancaniello, Respiratory Therapist Kelly Sullivan, Pharmacist Emily Durr, Pharmacist Marin Darsie, Physician Fellow Rhonda Cadena, Physician Attending Dedrick Jordan, Medical Director CICU Cristie Dangerfield, Nurse Manager Brooke Mclaughlin, CN IV Carrie Neal, CN IV Jonathan Cicci, Pharmacist Kamal Henderson, Physician Fellow Josh Roark, Physician Resident Jason Katz, Medical Director SICU Maureen Heck, Nurse Manager Sean Montgomery, Medical Director Shell Brownstein, Physician Attending Project Management Team Sean Miller Emelin Tan Julie Farmer Riane Hoffman Todd Hardy IHQI Tina Schade Willis Laura Brown 1

3 Project Aims Improve team performance and patient outcomes via a team-driven Daily Goals Tool in the Neurosciences ICU at UNC. Objectives Improve Care Delivery o o o Implement standardized rounding communication workflows within the ICU Promote adherence to ICU-specific QI initiatives Achieve 80% utilization rate of the Daily Goals Tool by July 2016 Improve Clinical Outcomes o Reduce hospital-associated complications and preventable patient harms 2

4 Medical Errors Reported as Number 3 Cause of U.S. Deaths New BMJ report estimates number of deaths attributable to medical errors is more than double estimated by To Err is Human in 1999 (250K vs 100K) Communication failures and human factors errors remain leading root causes of sentinel events and preventable medical errors Martin A Makary, and Michael Daniel BMJ 2016;353:bmj.i2139 3

5 Multiple Factors Threaten NSICU Team Communication >1300 alarms / 12 hr shift Data overload 3 documentation systems High-Risk Environment Avg Noise 55dBA (Eq. to low TV) Peak Noise 95dBA (Eq. to chainsaw) Multiple handoffs Transitional staff Rotating learners Priorities Vary Between Providers MD/APP Catheter/line removal Family meeting Sedation wean Nutrition Trach/Peg decision RN Patient mobilization Delirium screening Falls prevention Pressure ulcer prevention Pharmacist Antibiotic stewardship Adherence to VTE & GI prophylaxis Resp Therapist Lung protective ventilation Ventilator wean screen 4

6 Why Should We Use Daily Goals Tools? Daily goals tools foster a culture of collaboration, improve team coordination and communication, and facilitate individualized, goal-directed patient care. Daily goals tools improve outcomes and promote adherence to interventions known to decrease morbidity and mortality. Decrease errors of omission Reduce ICU Inertia Decrease length-of-stay Reduce hospitalassociated complications 5

7 Common Elements of Daily Goals Tools Checklists & Bundles Team Centric Daily Goals Tool Standardized Workflow Accountability Every Daily Goals Tool must be tailored to the unit and team One size does not fit all Most effective in conjunction with well-defined improvement protocols Single Platform for Multiple QI Initiatives Clear Roles & Responsibilities 6

8 The Success of Daily Goals Tools Depends Upon Much More Than Ticking Boxes: Not Just Another Piece of Paper 7

9 Daily Consistency Needed for Quality & Safety Focus Areas 100.0% 90.0% 80.0% 70.0% 60.0% NSICU Staff Survey: % Always Discussed on Rounds Staff report key quality and safety issues not addressed on daily basis All should be at 100% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 9

10 Team Communication Critical for Optimal Outcomes Case Studies in the NSICU Patient Issue Impact 52 y.o. woman with ruptured brain aneurysm Patient required tracheostomy but was not medically stable Trach decision by family not obtained by time patient stable, delaying trach by 5 days Patient developed pneumonia during delay LOS increased 69 y.o. man w/ large stroke Gastric tube placement recommended due to poor swallowing mechanism Night prior to G-tube placement, tube feeds held but insulin dose not adjusted Patient developed severe hypoglycemia 10

11 Daily Goals Tool is a Single Streamlined Platform for Multiple QI Initiatives Improvement Initiatives National ICU Liberation Initiative: Bundle Improvement Collaborative A: Assess, prevent & manage pain B: Both spontaneous awakening & spontaneous breathing trials C: Choice of analgesia & sedation D: Delirium E: Early mobility F: Family engagement NSICU Daily Goals Tool Institutional Patient Harms Reduction initiative Carolina Value (CAPP rounds, reduce LOS, improve transfers) TeamSTEPPS (effective team communication) Unit-Specific Early mobilization protocol CAUTI prevention VAP prevention Event reduction (falls & unplanned extubations) Delirium prevention VTE prevention Decrease length-of-stay Ventilation liberation Code status awareness Hypoglycemia prevention 11

12 Daily Goals Tool Used Across 24 Hour Cycle Overnight Night RN fills out new sheet for Nursing Report (May be used for RN shift handoff) RN gives Nurse Report NP reviews assessment and plan for each system RN fills out daily goals tool and recaps RN and MD sign Designed for compatibility w/ other NSICU communication workflows: CAPP rounds RN rounds reporting tool RN RN shift handoff MD/APP MD/APP shift handoff AM Rounds PM Check-In NP/resident and RN review goals Pertinent updates discussed w/ attending/fellow at evening sign-out 12

13 Multiple Iterative Revisions Necessary for Implementation (4 months) P: APP/residents perform recap of daily goals. D: APP/resident verbally recaps goals after assessment/plan. RN documents. All team members sign. S: Redundant. Inclusion of RN variable. Lacking closedloop communication. Inefficient. P: Attending/fellow recaps daily goals. D: Attending/fellow recaps goals. RN documents. All team members sign. S: Moderately redundant. Inclusion of RN variable. Lacking closed-loop communication. A: RN recaps goals. P: RN recaps goals. D: RN documents and recaps goals. Only RN and attending sign. S: Significantly less redundant. Reliable inclusion of RN. Closed-loop communication faster. A: Continue to evaluate opportunities for improving efficiency. Standardized Work Efficient Flow Easy to Use Closed-Loop Communication A: Attending/fellow recaps goals. o o o Challenges Increased length of rounds Variation across attendings/fellows PM daily goals review inconsistent 13

14 Significant Reduction in Catheter-Associated Urinary Tract Infections Median CAUTI Rate Per 1000 Foley Catheter Days Jan-14 Goal Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-15 Sep-15 Aug-15 Jul-15 Jun-15 May-15 Apr-15 Mar-15 Feb-15 Jan-15 Dec-14 Nov-14 Oct-14 NSICU Days Between CAUTI Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 NSICU historically unit with highest rate of CAUTI in UNC Healthcare System NSICU achieved >100 days CAUTI free in April 2016 Synergistic effect between Daily Goals Tool & institutional initiative Date of CAUTI 14

15 Ventilator-Acquired Pneumonia Trending Down Median VAP Per 1000 Vent Days Goal 2014 Q Q Q Q Q Q Q Q Q1 NSICU Days Between VAP 90 days VAP free as of May 2016 Not as dramatic improvement as CAUTI Need to develop more rigorous VAP prevention protocols Date of VAP 15

16 NSICU Reliably Discussing Quality & Safety Focus Areas 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% NSICU AM Daily Goal Sheet % Completion (3 week April/May Audit) Neuro Resp. Reno/Endo. ID Patient Quality Sign-Off 100.0% 80.0% 60.0% 40.0% 20.0% PM Daily Goal Sheet Sign-Off % Completion Highest consistency on Neuro initiatives PM check-in process needs more focus 0.0% RN NP/Resident Both 16

17 Team Testimony Rhonda Cadena, MD NSICU Physician The daily goals tool gets us talking every day about important things that might have been missed otherwise. Having a daily goal for mobility has really been getting patients moving. Communication has improved considerably and everyone understands the plan when we are done. Shelly Tessitore, RN ICU Flex Nurse The behavior surrounding the tool was probably what made it most successful. For example, in some units with checklists, the MDs start rounding without the nurse, yet it s the nurse that s supposed to be doing the checklist. The [Daily Goals Tool] is basically encouraging us to behave as a team. The RN on night shift used the tool to help give me report in the morning. It helped me understand what the goals of the prior shift were, and what the goals going forward were. 17

18 Team Testimony Megan Brissie, DNP, RN, ACNP NSICU Nurse Practitioner "The goal sheet encourages daily mobilization of patients in the NSICU to achieve the highest most appropriate daily mobilization goals. When goals are not achieved, discussion regarding the barriers to mobilization are addressed to ensure safe mobilization can be achieved the following day" 18

19 Lessons Learned o Leadership commitment is critical. Leadership must reinforce that the daily goals tool is mandatory. o Strong representation required from each stakeholder group. o Daily goals tool must be integrated into surrounding workflow and communication processes. o Daily goals tool most successful in combination with clearly defined improvement initiatives and protocols. o Implementation may increase duration of rounds. 19

20 Sustainability Near term o Continue refining goal sheet content and process o New staff (i.e. residents and fellows) education (July) o Post-intervention data collection (Aug-Oct) o Develop compliance reports for unit leadership o Enable unit leadership to provide feedback to frontline staff Long term o Develop process to systematically update goal sheet content based on evolving unit quality improvement priorities o Next focus: Communication of daily goals to patients/families o Improve data collection for outcomes metrics o Continue standardizing protocols for unit improvement priorities (ex. VAP) o Ongoing education for new/rotating staff 20